Adult Neurodevelopmental Assessment Intake
Please complete this intake questionnaire to help us understand your background and current concerns for your neurodevelopmental assessment.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
What is the main reason for seeking a neurodevelopmental assessment?
*
Have you ever been diagnosed with any of the following?
Autism Spectrum Disorder
Attention Deficit Hyperactivity Disorder (ADHD)
Learning Disability
Intellectual Disability
None of the above
Other
Please rate the following symptoms based on your experiences over the past 6 months.
*
Rows
Never
Sometimes
Often
Very Often
Difficulty sustaining attention
1
2
3
4
Restlessness or fidgeting
5
6
7
8
Difficulty organizing tasks
9
10
11
12
Forgetfulness in daily activities
13
14
15
16
Trouble following instructions
17
18
19
20
Impulsivity (acting without thinking)
21
22
23
24
Difficulty with social interactions
25
26
27
28
Sensitivity to sensory input
29
30
31
32
Educational Background
Please Select
High school or less
Some college/technical training
Bachelor's degree
Graduate or professional degree
Other
Are you currently taking any medications?
Yes
No
If yes, please list your current medications (name and dosage):
Do you have a family history of neurodevelopmental or psychiatric conditions?
Yes
No
Not sure
Is there anything else you would like us to know about your background or current concerns?
Submit Intake Questionnaire
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